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122 Making General Practice Attractive: Encouraging GP attraction and Retention KCE Reports 90 7.3.3 Financial policies supported by the stakeholders When asked to pick financing policies, the majority of the stakeholders chose to mix fee-for-service with capitation as a complementary mechanism of funding. The policy on incentives for the installation in a low density area had a good score but was not the main priority of the stakeholders; this could be due to the fact that Impulseo I has been recently started, thus is no longer a priority or, as suggested by the literature, a oneshot lump sum does not compensate, on the longer term, for poorer working conditions. Thus when confronted with the need to choose a policy, capitation might have been picked because this is still a rather new policy in the Belgian context. Indeed, capitation funding currently applies only to 165,000 patients registered under the "maison médicale/ wijkgezondheidscentra" scheme while the other (majority) GPs can receive 25€ per patient through the “Global Medical Record” (DMG-GMD) scheme. Authors from the European Observatory on Health systems and policies suggest that there is room for improving the role of capitation in the funding of GPs 222 . Interviewed students were more reluctant to the idea of capitation. This might be explained by the wording of the question: the students were asked to choose for capitation instead of fee-for-service whereas the question asked to the stakeholders was about capitation as an additional way of financing general practice. These are of course, very different policies. Clearly, our study suggests that there is no room for removing the fee-for-service scheme but more for a diversification of the funding mechanism. This is also very consistent with current trends in physicians payment mechanisms 224 . 7.4 WORKING CONDITIONS Working conditions of general practitioners are a general concept including the many aspects of general practice influencing the job satisfaction and satisfaction in the lifestyle. This includes two main themes: the working schedule and its influence on the work-life balance and the working organisation such as team-work. These elements and particularly the first one, are considered as major drivers of physician satisfaction 225 . 7.4.1 Different perceptions of the GP working conditions The literature review and the Belgian GP leavers study stress the importance of working conditions as key factors for retention. Leaving general practice was the result of high demand such as work load, having to be constantly on-call, dealing with emergencies, high responsibilities and the perceived burden of continuous medical education. These high demands were in conflict with personal responsibilities, like family life. The students hold, however, conflicting views about working conditions. On one hand general practice is perceived as a difficult profession with a lot of uncertainties (especially for the clinical decision process) and a lonely job with a high workload. On the other hand, the GP profession is appreciated for its variety in the work, autonomy and the privilege of working with patients in different stages of their life. An interesting finding is that general practice students hold a more positive opinion than other specialty students regarding how difficult general practice could be. Students choosing a specialty career considered general practice as a more lonely profession than the students in general practice did: this may suggest either that the expectations regarding team-work are different between these two groups of students or that these groups hold a different perception of the reality of GP team-work. Our study supports both explanations. The student study shows that the expectations regarding team working do not differ largely between GP students and specialist students. However, GP students did have a slightly higher preference for “flexible” schedule while specialist students valued more heavily “job security”. This could explain why students hold different perspectives on the GP’s work: for the GP students: the costs of working alone as a GP is slightly paid off by the positive return of its corollary, autonomy. This trade-off may apply less to specialist student which tend to value more job security than autonomy. The stakeholders' survey supports this hypothesis: they gave the same weight to autonomy and team working: both values were important. This suggests that
KCE Reports 90 Making General Practice Attractive: Encouraging GP attraction and Retention 123 the issue of team-working is difficult for the GP profession because it entails a struggle between two important values: autonomy and team-work. The leavers’ study confirmed that group practice is not such a magic bullet : the loss of autonomy when working in group practice can also be a reason why some general practitioners leave the profession. 7.4.2 Suggested policies to improve the working conditions in general practice The best ranked policies in the stakeholders’ survey were supporting a career with new professional opportunities and scrapping the individual on-call obligation. However, the stakeholders gave them rather low score in comparison with other policies. The reason might be that new professional opportunities (like teaching and research) are regarded as feasible for those working in a group of GPs, in order not to jeopardize the continuity of care and the accessibility of the practice. Thus, this comes as no surprise that encouraging the GPs to work in group (a policy initially considered under the health system organization heading) was among the most supported policies in the stakeholders study). Indeed, team-working does not only make possible to have other professional responsibilities but also to delegate administrative tasks to assistant staff and to get access to Information Technologies infrastructure whose cost is prohibitive for GPs working in solo practice. It also allows the GP to have a more active role in a multidisciplinary team work that allows the GP to get a stronger role for instance in the care for chronic patients and frail elderly patients. Also, GP students were very keen with the idea of having a practice support staff although it was unclear whether they understood that this support staff was linked to the work in a group-practice. Removing the individual obligation for on-call duties and replacing it by deputizing services showed to be controversial measures. Most stakeholders agreed that these policies were good for attracting and retaining GPs but they bothered about their sideeffect particularly on accessibility and on cost for the health care system. Moreover, the profession itself seems to be divided on that topic. GP students were quite in favor of a deputizing service and GP leavers also raised this idea as a policy that would have made their life easier. But it was not clear, according to the GP stakeholders, whether the on-call duties obligation should be scrapped. This is a paradox: work-life balance is jeopardized by the individual on-call duty but GPs stakeholders are not so keen to scrap it. A reason could be that by calling public authorities into rescue for organizing deputy services, the profession risks loosing its current grasp on-call service through the GP "cercles/kringen". Scrapping individual on-call obligation will thus transfer the responsibility to another –possibly governmental- body and, hence, affect the profession's autonomy at the local level. 7.5 HEALTH SYSTEM ORGANIZATION It is impossible to disconnect the issues addressed in this report from the other domains of the health system organisation. GPs’ drop-out from family medicine is observed in many OECD countries and there are some indications that the role of the GP within the health care system can be improved. Indeed, the literature review concluded that the place and organization of primary healthcare, as well as the role of GPs within the health care system may influence indirectly physician supply and therefore the shape, the relevance and feasibility of attraction-recruitment-retentionpolicies. For example, some health care systems do allow for an improved role of a physician assistant or nurse practitioner, allowing the GP to have less administrative tasks to carry on. Belgium is considered as a country with a low level of professional collaborative relationships compared with other European countries. Care integration (kind and magnitude of the links between the different health care actors) is the key issue to which we now turn. The health system organization policies got high scores among stakeholders study, much higher than financing or work-life balance policies. This suggests that the stakeholders are aware of the fact that GP attraction and recruitment is linked to the organisation of the Belgian health care system. In general, they were very keen but cautious with these kinds of policies. They supported policies favoring group practice including the
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